Adolescents’ lived experiences of facility-based childbirth in rural northern Uganda: A qualitative study

Sub-theme 1.1: Effective interaction

Most of the participants interviewed expressed positive experiences of care related to cordial interactions with healthcare providers during their childbirth journey. They highlighted that the midwives talked to them in a friendly manner and communicated respectfully as typified by responses from these participants:

“She was humble while talking to me and was not rude. They were talking calmly to me.” (Scarlett, 18-year-old, Para 1)

The positive interactions with adolescents resulted in words of encouragement as in the case of a teenager giving birth for the second time:

“She was interacting well with me and she said I should persevere and I will give birth well.” (Amelia, 18-year-old, Para 2)

How the healthcare provider interacted with the adolescents influenced their experience of care during the process of labour and childbirth. Most of the adolescents did not have any problem with how the midwives communicated with them as noted below:

“She told me nothing that would make me have problems with her.” (Chloe, 19-year-old, Para 1)

Sub-theme 1.2: Provision of information

The responsibility of answering questions and addressing concerns usually falls on the skilled health personnel who look after the labouring woman. Midwives are suited for this role since they spend the most time with women in labour. Providing health information is critical in creating a positive birth experience, especially for adolescents who might be giving birth for the first time.

“They kept telling me even the time I was giving birth they told me that I should push the baby [when I feel the contraction is strong].” (Amelia, 18-year-old, Para 2)

The recurring use of the phrase “they kept telling me” underscores a continuous and supportive communication flow. For some adolescents, telling them when they would give birth, and the progress of labour greatly improved their experiences of childbirth:

“I was told there was progress [participant smiled] and I was asked to be walking around. I then walked around but reaching around 7:00 pm, things became hot and I gave birth at 9:00 pm.” (Grace, 18-year-old, Para 1)

Sub-theme 2.1: Respectful care

Participants emphasised the nuanced ways in which respect was demonstrated, highlighting a holistic approach to care that extended beyond verbal communication. This was embodied by a quote from one of the participants who was an orphan and came to give birth in the hospital alone:

“When I reached, the midwife gave me the bed where I was admitted. She [midwife] then asked me to pick the urine mat [mackintosh] and go with it to labour suite and she examined me very well. She [midwife] was humble while talking to me” (Scarlett, 18-year-old, Para 1)

One of the youngest participants, Ella aged 16 years perceived and reported respect while receiving care as noted below:

“…there was maximum respect” (Ella, 16-year-old, Para 1)

While participants were not sure how they would be treated during childbirth, they reported respectful care with a lack of mistreatment as illustrated by quotes from some of these participants:

“I was not slapped at all. There was no issue and the nurse was the one who helped me to push the baby without any problem, they didn’t quarrel with me, and I wasn’t told anything. I gave birth smoothly because I didn’t go through hardship it was just okay”. (Sophia, 17-year-old, Para 1)

Sub-theme 2.2: Friendly care

Many participants indicated a positive shift in the caregiver’s approach, signalling a transition from professional care to a more personal, friendly connection. The adolescents experienced friendly care which was perceived in the form of general love and liking for them during care. This suggested a nurturing environment, where emotional well-being was recognised as integral to overall health as reported by some of these participants:

“She started being friendly to me during my pregnancy…. Ever since I started my antenatal visit, she showed me love.” (Chloe, 19-year-old, Para 1)

Sub-theme 3.1: Hospitable care

Most of the participants expressed positive experiences related to the hospitality they received during childbirth. The hospitable care was seen by adolescents as a warm welcome and respectful reception upon arrival at the health facility:

“Labour pain started on Monday night and then I went to the hospital on Tuesday around 4:30 pm, we were well received, and I was given necessary services and I never got any problem.” (Susan, 18-year-old, Para 1)

Sub-theme 3.2: Encouragement

The healthcare providers encouraged and reassured the adolescents during labour which fostered a positive experience during childbirth. Some participants were reassured about the outcome of pregnancy. This encouraged them to go through the experience of childbirth as teenage mothers as cited by these participants:

“She said I should persevere [the labour pain] and that I will give birth well [implying there will be no complication].” (Amelia, 18-year-old, Para 2)

For some adolescents, the absence of complications during labour was used by skilled health personnel to motivate them. Some healthcare providers used the fact that in recent times, adolescents were having normal spontaneous vaginal birth even more than older women to inspire adolescents in labour.

“The nurse told me that my childbirth would be okay without any complication and also said that young girls are giving birth without complications compared to old women” (Sophia, 17-year-old, Para 1)

Some participants expressed gratitude to the skilled health personnel for encouraging them to ambulate throughout labour which resulted in a positive birth experience:

“She also encouraged me to exercise by helping me to walk around while talking to me happily.” (Chloe, 19-years-old, Para 1)

Sub-theme 3.3: Partnership with the adolescents

Participants emphasised the importance of skilled health personnel forming a partnership with them during the childbirth process. This collaboration in the form of physical presence and quality of care, contributed to a sense of trust and support as typified by feedback from some of the participants:

“One important thing that I know is the nurse [midwife] was on my side. She gave me hope and confidence to give birth without any problem.” (Sophia, 17-year-old, Para 1)

Some of the midwives cleaned up the mothers and supported them so that they did not fall off the bed while wrestling with labour pain on the delivery bed:

“The midwife was with me up to the time I gave birth. She even cleaned me up.” (Scarlett, 18-year-old, Para 1)

Sub-theme 3.4: Companionship during labour and childbirth

Besides the partnership the adolescents had with the midwives during childbirth, most of the participants highlighted the presence and support of birth companions of their choice during labour and childbirth. The presence of supportive companions, such as family members and traditional birth attendants, played a key role in shaping the labour and childbirth experiences of adolescents through the provision of emotional and practical support:

“My neighbour who is a traditional birth attendant went with me and was present in the labour suite during childbirth.” (Susan, 18-year-old, Para 1)

Sub-theme 3.5: Timely care

Participants noted that they received timely care during their childbirth experiences.

“Immediately I reached, they took me to the examination room, I was examined and told I was about to give birth.” (Susan, 18-year-old, Para 1)

Sub-theme 4.1: Clean labour suite and ward

Within the health facility, participants consistently appraised the cleanliness of the labour suite and general ward as integral components of their overall experience. Their sentiments, encapsulated in the following excerpts, underscore the significance attributed to the hygiene of these critical spaces:

“The place was generally clean like the labour suite, the floor was clean because immediately someone delivers the place would be cleaned up and even the toilets.” (Ella, 16-year-old, Para 1)

Although each healthcare facility has designated cleaners, in other cases, the adolescents accepted to clean the delivery bed and the labour suite floor themselves to enlist favourable treatment from the healthcare providers as was the case for Chloe:

“As a person who has just given birth you need to clean the labour bed and floor which I didn’t get any problem with it and that made them [midwives] to like me.” (Chloe, 19-years-old, Para 1)

Sub-theme 4.2: Clean toilet and bathroom

Complementary to the appraisal of the labour suite and ward as clean, participants articulated their satisfaction with the cleanliness of toilet and bathroom facilities within the health facility. This sub-theme underscores adolescents’ discernment of sanitation beyond the immediate context of childbirth, extending to the ancillary areas crucial for their overall well-being. Although it was not very clean, the participants felt that the hygiene of the toilets and the bathrooms was good as cited by some of these participants:

“The washrooms were generally clean like the bathroom and toilet I had to clean after I had used.” (Emily, 17-year-old, Para 2)

In other health facilities, either the toilet or bathroom was not clean at any given point in time as noted by some of these participants:

“The place where I got services from was clean, the toilet was good, it was the bathroom that was not clean and was unbearable.” (Susan, 18-year-old, Para 1)

Sub-theme 5.1: Physical abuse

Physical abuse was one form of D&A experienced by adolescent mothers during childbirth. Some adolescents recounted incidents of physical abuse which included slapping, inappropriate examination, and repair of the episiotomy without anesthesia as noted below:

“I was stitched [after episiotomy] but it was very painful, I was stitched without put on anesthesia”. (Lily, 17-year-old Para 1)

One participant described a midwife’s act that resulted in immediate physical harm:

“Hmm, she [the midwife] gave me a very terrible slap on my thigh, and my thigh got paralysed instantly.” (Mia, 18-year-old, Para 1)

The presence of relatives of the adolescents did not stop the midwife from physically assaulting the labouring adolescent as noted by one of the participants:

“I was slapped like twice even and my stepmother was just there looking. [Besides], she was touching [palpating] me in a painful way.” (Lily, 17-year-old Para 1)

Sub-theme 5.2: Verbal abuse

Verbal abuse by midwives was a common form of D&A experienced by these participants during childbirth. They reported that midwives used harsh language and demeaning comments towards them, while others were judgmental and critical of them. Verbal abuse also manifested in the form of threatening adolescents regarding the likely adverse birth outcomes associated with adolescent pregnancies which created a sense of fear among adolescents.

“They said that I should open up my vagina well because they are not the ones who inserted my husband’s penis into my vagina.” (Mia, 18-year-old, Para 1)

Some of the adolescents were scolded for being out of school and getting pregnant at a tender age, something they resented and made them feel unwelcome at the health facility.

“Mm, I was also told I should go back to school that I am still young to be in marriage [started to look away in anger].” (Emily, 17-year-old, Para 2)

Sub-theme 5.3: Neglect and abandonment

Participants shared distressing accounts of being left alone during labour, such as one of the participants who delivered without assistance. This neglect and abandonment during childbirth exposed adolescents to heightened vulnerability.

“I delivered alone and the nurse [midwife] only received the baby.” (Emily, 17-year-old, Para 2)

In some instances, the healthcare providers were not present in the hospital and the relatives had to call the healthcare providers from the staff quarters to attend to the adolescent mothers or assist the adolescent mother to give birth without the help of a midwife.

“By the time I was in labour pain, it was so serious and they went to call the midwife and when she arrived, I had already given birth because my husband didn’t know where the staff room was so he kept knocking one door after the other”. (Campbell, 19-year-old, Para 2)

Sub-theme 5.4: Non-consented care

Despite positive initial interactions, some of the participants reported that they were not allowed to exercise their rights for self-determination during childbirth which may have violated their rights. Some were denied the opportunity to choose their preferred birthing position while others were examined without seeking their consent.

“She instructed me to lay and lift my legs which I did but at one point I pushed and then my energy got depleted but she kept on shouting at me that I should hurry up pushing the baby.” (Grace, 18-year-old, Para 1)

Sub-theme 5.5: Disempowerment

Participants shared experiences of feeling disempowered during healthcare encounters. Disempowerment was perceived by the adolescents as limited opportunities to ask questions regarding their labour process, hospital dynamics, and/or their well-being and that of their babies:

“I wasn’t given any opportunity to ask even a single question and the way I was treated I could hardly ask any question.” (Mia, 18-year-old, Para 1)

In some cases, the midwives covertly placed adolescents under duress to name their babies after them as narrated in the excerpts below:

“He told me I should name my child after him. I did not tell him [I didn’t want to name my child after him]. I was fearing he would shout at me.” (Amelia, 18-year-old, Para 2)

Sub-theme 5.6: Bribery and extortion

Many of the participants expressed instances of financial exploitation which reflected a system where unofficial payments were often required for various aspects of care. Adolescent mothers felt coerced to comply because of the fear of the likely neglect and abandonment that could result from failure to pay the bribe/extortion fees. In public health facilities in Uganda, mothers are not required to buy any medicine or supplies while receiving care, but this was not the case with the care of some of the adolescents. Some of these unofficial payments were disguised as the mother’s contribution towards buying cleaning agents, gloves, and toilet paper as noted below:

“She was asking for detergent, washing soap, and then my mother-in-law bought and I said since she has helped me so much, I will get something and visit her at her home.” (Chloe, 19-year-old, Para 1)

In some instances, the bribery and extortion were concealed as payments for birth registration, and birth registration cards were retained until adolescents paid for the card as remarked by some of these participants:

“We had carried Ugx. 25,000 (USD 7) of which my husband had just borrowed. Everyone was paying for the card and if you have not paid you would not be given the card. Both young and old women were paying the same amount before getting the card.” (Ella, 16-year-old, Para 1)

Meanwhile, in other cases, the healthcare providers bluntly asked the mothers to give them money as a token of appreciation, a form of corruption as noted below:

“[…] They asked for some money and I think they were given Ugx. 15.000 [USD 4.2] because I didn’t pay much attention to that since my mother-in-law was there to handle.” (Ella, 16-year-old, Para 1)

Sub-theme 6.1: Dirty toilets and bathrooms

Some participants provided varied perspectives on the cleanliness of the facility, specifically highlighting concerns about the state of toilets and bathrooms:

“It is the toilets that sometimes could be dirty in that you find faeces and urine on the floor and no one bothers to clean it, and the bathrooms sometimes were very dirty. You could find that those women who have just delivered have bathed and their blood flooded on the floor.” (Chloe, 19-year-old, Para 1)

Participants expressed that while the hygiene in the labour suite was maintained in some cases, the hygiene in the toilets and bathrooms was poor. This compelled some of them to clean the bathrooms and toilets themselves before use or to simply use the facilities the way they were:

“The toilets and bathrooms were not clean at all, I had no choice but to [clean it myself] and bath in it like that.” (Campbell, 19-year-old, Para 2)

Sub-theme 6.2: Unstable water supply

Concerns were raised regarding the stability of water supply as a basic amenity required for the maintenance of facility hygiene as well hygiene of clients. Unstable water supply was cited as the main cause of the dirty bathrooms and toilets. These concerns are personified in quotes from some of these adolescents:

“Sometimes there would be no water most especially if the borehole breaks down and at times when there is water you find that attendants are not willing to do the cleaning.” (Chloe, 19-years-old, Para 1)

Sometimes, the participants were forced to fetch water from outside the hospital premises due to inconsistent or complete lack of water supply within the facility, which not only added to their physical burden during a vulnerable time but also compromised their access to basic hygiene and sanitation, thereby affecting their overall childbirth experience.

“There is water, tap water but there was a time when it was off the entire night but then it got back the following morning. Water was being collected from [a secondary school located about 2 km from the health facility] and was far.” (Susan, 18-year-old, Para 1)

Sub-theme 6.3: Shortage of essential medicines and supplies

Some participants shared experiences where there were no essential medicines for managing common complications during pregnancy and childbirth. One of the interviewees never received any treatment during labour because of a lack of medicines although the doctor had told her that she needed medications.

“I was not injected till I returned home. I was not given any kind of medication and they told me that if I were to be treated then I needed to buy medication which I didn’t have money.” (Chloe, 19-year-old, Para 1)

For some participants, they were required to purchase all the gloves used during their care. This was after being informed by the healthcare providers that there were no gloves available in the hospital stock.

“All the gloves that were used are the ones we bought, we bought four pairs”. (Mia, 18-year-old, Para 1)